A NOTE FOR SCHOOL A NOTE FOR SCHOOL

Teacher Teacher
Office Office
Other: ______________________ Other: _____________________
Today’s Date: _____ / _____ / _____ Today’s Date: ____ / _____ / _____

Student Name: ________________________________________ Student Name: ________________________________________

Teacher: ______________________________ Grade: _________ Teacher: ______________________________ Grade: _________
Parent/Guardian Signature: _____________________________ Parent/Guardian Signature: _____________________________

ABSENCE/TARDINESS (please circle one): ABSENCE/TARDINESS (please circle one):

was absent was late to school was absent was late to school
will be absent will be late to school will be absent will be late to school
On date(s): ____________________________________________ On date(s): ____________________________________________
Due to: _______________________________________________ Due to: _______________________________________________

PICK UP/LEAVE EARLY PICK UP/LEAVE EARLY

will be picked up by: ________________________
At (please circle one): dismissal or ____:____ AM/PM
Contact Number: ( ____ ) ______ - ________
will leave early _____ / _____ / _____ @ ____:____
Due to: _________________________________________
will be picked up by: ________________________
At (please circle one): dismissal or ____:____ AM/PM
Contact Number: ( ____ ) ______ - ________
will leave early _____ / _____ / _____ @ ____:____
Due to: _________________________________________

MONEY ENCLOSED MONEY ENCLOSED

Amount: $ ____________ Please circle one: cash check Amount: $ ____________ Please circle one: cash check
For (please circle one): For (please circle one):
Lunch Field Trip Books Other: _____________ Lunch Field Trip Books Other: _____________

OTHER: ____________________________________________ OTHER: ____________________________________________

FOR OFFICE USE
 FOR OFFICE USE

Time: ______________ Initials: ______________ Time: ______________ Initials: ______________